Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

MIDODRINE 10 MG TABLET [33083]

Facility

$6.00

Service Code	NDC 60687040925
Hospital Revenue Code	250
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: MDX Hawaii PPO	$5.82

MIDODRINE 10 MG TABLET [33083]

Facility

$6.00

Service Code	NDC 60687040925
Hospital Revenue Code	637
Min. Negotiated Rate	$3.06
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$3.60
Rate for Payer: Hawaii Western Management Group Commercial	$5.70
Rate for Payer: Health Management Network Commercial	$5.10
Rate for Payer: Kaiser Permanente Commercial	$3.78
Rate for Payer: Kaiser Permanente Medicaid	$3.06
Rate for Payer: MDX Hawaii PPO	$5.82
Rate for Payer: University Health Alliance Commercial	$4.37

MIDODRINE 5 MG TABLET [10610]

Facility

$4.00

Service Code	NDC 60687039811
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: University Health Alliance Commercial	$2.92

MIDODRINE 5 MG TABLET [10610]

Facility

$4.00

Service Code	NDC 60687039811
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

MIDODRINE 5 MG TABLET [10610]

Facility

$4.00

Service Code	NDC 60687039801
Hospital Revenue Code	250
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: MDX Hawaii PPO	$3.88

MIDODRINE 5 MG TABLET [10610]

Facility

$4.00

Service Code	NDC 60687039801
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$2.40
Rate for Payer: Hawaii Western Management Group Commercial	$3.80
Rate for Payer: Health Management Network Commercial	$3.40
Rate for Payer: Kaiser Permanente Commercial	$2.52
Rate for Payer: Kaiser Permanente Medicaid	$2.04
Rate for Payer: MDX Hawaii PPO	$3.88
Rate for Payer: University Health Alliance Commercial	$2.92

MIFEPRISTONE 200 MG TABLET [28975]

Facility

$108.00

Service Code	NDC 64875000101
Hospital Revenue Code	250
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$104.76
Rate for Payer: Cash Price	$64.80
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: MDX Hawaii PPO	$104.76

MIFEPRISTONE 200 MG TABLET [28975]

Facility

$108.00

Service Code	NDC 64875000101
Hospital Revenue Code	637
Min. Negotiated Rate	$55.08
Max. Negotiated Rate	$104.76
Rate for Payer: Cash Price	$64.80
Rate for Payer: Hawaii Western Management Group Commercial	$102.60
Rate for Payer: Health Management Network Commercial	$91.80
Rate for Payer: Kaiser Permanente Commercial	$68.04
Rate for Payer: Kaiser Permanente Medicaid	$55.08
Rate for Payer: MDX Hawaii PPO	$104.76
Rate for Payer: University Health Alliance Commercial	$78.72

MIGRAINE & OTHER HEADACHES

Facility

$7,632.29

Service Code	APR-DRG 0544
Min. Negotiated Rate	$7,632.29
Max. Negotiated Rate	$7,632.29
Rate for Payer: AlohaCare Medicaid	$7,632.29
Rate for Payer: Hawaii Medical Service Association ABD	$7,632.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,632.29
Rate for Payer: Kaiser Permanente Medicaid	$7,632.29
Rate for Payer: Ohana Health Plan Medicaid	$7,632.29
Rate for Payer: UnitedHealthcare Medicaid	$7,632.29

MIGRAINE & OTHER HEADACHES

Facility

$2,686.73

Service Code	APR-DRG 0541
Min. Negotiated Rate	$2,686.73
Max. Negotiated Rate	$2,686.73
Rate for Payer: AlohaCare Medicaid	$2,686.73
Rate for Payer: Hawaii Medical Service Association ABD	$2,686.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,686.73
Rate for Payer: Kaiser Permanente Medicaid	$2,686.73
Rate for Payer: Ohana Health Plan Medicaid	$2,686.73
Rate for Payer: UnitedHealthcare Medicaid	$2,686.73

MIGRAINE & OTHER HEADACHES

Facility

$4,145.87

Service Code	APR-DRG 0543
Min. Negotiated Rate	$4,145.87
Max. Negotiated Rate	$4,145.87
Rate for Payer: AlohaCare Medicaid	$4,145.87
Rate for Payer: Hawaii Medical Service Association ABD	$4,145.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,145.87
Rate for Payer: Kaiser Permanente Medicaid	$4,145.87
Rate for Payer: Ohana Health Plan Medicaid	$4,145.87
Rate for Payer: UnitedHealthcare Medicaid	$4,145.87

MIGRAINE & OTHER HEADACHES

Facility

$3,309.65

Service Code	APR-DRG 0542
Min. Negotiated Rate	$3,309.65
Max. Negotiated Rate	$3,309.65
Rate for Payer: AlohaCare Medicaid	$3,309.65
Rate for Payer: Hawaii Medical Service Association ABD	$3,309.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,309.65
Rate for Payer: Kaiser Permanente Medicaid	$3,309.65
Rate for Payer: Ohana Health Plan Medicaid	$3,309.65
Rate for Payer: UnitedHealthcare Medicaid	$3,309.65

MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK [137869]

Facility

$64.00

Service Code	HCPCS J2260
Hospital Revenue Code	250
Min. Negotiated Rate	$54.40
Max. Negotiated Rate	$62.08
Rate for Payer: Cash Price	$38.40
Rate for Payer: Health Management Network Commercial	$54.40
Rate for Payer: MDX Hawaii PPO	$62.08

MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK [137869]

Facility

$64.00

Service Code	HCPCS J2260
Hospital Revenue Code	636
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$62.08
Rate for Payer: Cash Price	$38.40
Rate for Payer: Cash Price	$38.40
Rate for Payer: Hawaii Medical Service Association ABD	$1.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.40
Rate for Payer: Hawaii Western Management Group Commercial	$60.80
Rate for Payer: Health Management Network Commercial	$54.40
Rate for Payer: Kaiser Permanente Commercial	$40.32
Rate for Payer: Kaiser Permanente Medicaid	$32.64
Rate for Payer: MDX Hawaii PPO	$62.08
Rate for Payer: UnitedHealthcare Medicaid	$38.40
Rate for Payer: University Health Alliance Commercial	$46.65

MINERAL OIL ENEMA [5087]

Facility

$13.00

Service Code	NDC 00132030140
Hospital Revenue Code	637
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$8.19
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: University Health Alliance Commercial	$9.48

MINERAL OIL ENEMA [5087]

Facility

$13.00

Service Code	NDC 00132030140
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: MDX Hawaii PPO	$12.61

MINERAL OIL, LIGHT STERILE [209376]

Facility

$69.00

Service Code	NDC 25410000000
Hospital Revenue Code	637
Min. Negotiated Rate	$35.19
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$41.40
Rate for Payer: Hawaii Western Management Group Commercial	$65.55
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$43.47
Rate for Payer: Kaiser Permanente Medicaid	$35.19
Rate for Payer: MDX Hawaii PPO	$66.93
Rate for Payer: University Health Alliance Commercial	$50.29

MINERAL OIL, LIGHT STERILE [209376]

Facility

$69.00

Service Code	NDC 25410000000
Hospital Revenue Code	250
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$41.40
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: MDX Hawaii PPO	$66.93

MINI QA+ #2/O OCARD V-5 212035

Facility

$2,367.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,325.52
Max. Negotiated Rate	$2,295.99
Rate for Payer: Cash Price	$1,420.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,656.90
Rate for Payer: Health Management Network Commercial	$2,011.95
Rate for Payer: MDX Hawaii PPO	$2,295.99
Rate for Payer: University Health Alliance Commercial	$1,325.52

MINI QA+ #2/O OCARD V-5 212035

Facility

$2,367.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,207.17
Max. Negotiated Rate	$2,295.99
Rate for Payer: Cash Price	$1,420.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,656.90
Rate for Payer: Health Management Network Commercial	$2,011.95
Rate for Payer: Kaiser Permanente Commercial	$1,491.21
Rate for Payer: Kaiser Permanente Medicaid	$1,207.17
Rate for Payer: MDX Hawaii PPO	$2,295.99
Rate for Payer: University Health Alliance Commercial	$1,325.52

MINIRAIL HORIZ ARTIC M111

Facility

$2,484.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,111.40
Max. Negotiated Rate	$2,409.48
Rate for Payer: Cash Price	$1,490.40
Rate for Payer: Health Management Network Commercial	$2,111.40
Rate for Payer: MDX Hawaii PPO	$2,409.48

MINIRAIL HORIZ ARTIC M111

Facility

$2,484.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,266.84
Max. Negotiated Rate	$2,409.48
Rate for Payer: Cash Price	$1,490.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,359.80
Rate for Payer: Health Management Network Commercial	$2,111.40
Rate for Payer: Kaiser Permanente Commercial	$1,564.92
Rate for Payer: Kaiser Permanente Medicaid	$1,266.84
Rate for Payer: MDX Hawaii PPO	$2,409.48
Rate for Payer: University Health Alliance Commercial	$1,810.59

MINIRAIL LONG 135/5MM M102

Facility

$2,484.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,266.84
Max. Negotiated Rate	$2,409.48
Rate for Payer: Cash Price	$1,490.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,359.80
Rate for Payer: Health Management Network Commercial	$2,111.40
Rate for Payer: Kaiser Permanente Commercial	$1,564.92
Rate for Payer: Kaiser Permanente Medicaid	$1,266.84
Rate for Payer: MDX Hawaii PPO	$2,409.48
Rate for Payer: University Health Alliance Commercial	$1,810.59

MINIRAIL LONG 135/5MM M102

Facility

$2,484.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,111.40
Max. Negotiated Rate	$2,409.48
Rate for Payer: Cash Price	$1,490.40
Rate for Payer: Health Management Network Commercial	$2,111.40
Rate for Payer: MDX Hawaii PPO	$2,409.48

MINIRAIL SHORT 32/5MM M103

Facility

$2,484.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,111.40
Max. Negotiated Rate	$2,409.48
Rate for Payer: Cash Price	$1,490.40
Rate for Payer: Health Management Network Commercial	$2,111.40
Rate for Payer: MDX Hawaii PPO	$2,409.48

Know your out-of-pocket cost for care.

All Charges